Description

Problem Statement – Version 1

57 year old male, construction/flooring worker, without previous medical records and absent from preventative health screenings for several years. Patient self reports history of acid reflux treated with OTC omeprazole, bilateral knee pain treated with OTC ibuprofen. Surgical history of ACL repair, unknown date. Patient without well balanced nutrition, consumes elevated processed foods high in fat and sodium. Patient presents to office today for evaluation of elevated blood pressure reading, approximately 170/92, at community wellness event. Patient denies history of hypertension or cardiac disease. Blood pressure in office is elevated L:172/94 R: 178/98. Patient denies palpitations, chest pain, dizziness, SOB or cardiac history. Significant family history for Diabetes, HTN, Stroke, and MI.

Problem Statement – Version 2

A 57 year old male presents to the office with complaints of high blood pressure. No established history with a primary care provider. Has not had preventative screenings. History of bilateral knee pain from years of flooring worker/construction worker. Smoker of 1 pack a day for approximate 37 years. Consumes alcohol on weekends. Consumes caffeine with unhealthy diet. High blood pressure reading at a Health Fair 170/92. Denies chest pain, shortness of breath, palpitations and headache. Self medicates with OTC Omeprazole for GERD and Motrin OTC for pain.

Problem Statement – Version 3

57 years old overweight male that works in construction. He presents today for an evaluation of an elevated BP at a health fair. He reports some gastritis and “achy knees.” Patient currently takes OTC omeprazole and NSAIDS. BP 172/94 L and 178/98 R and funduscopic findings of A-V nicking were discovered upon examination. Patient has a family hx of hypertension and diabetes. Patient was told he had elevated BP in past but did not seek treatment. Patient is at risk for OSA due to age, gender, and HTN.

Problem Statement – Version 4

57 year old, Hispanic male, construction worker, presenting with high blood pressure after a visit to health fair. Physical findings include BP:172/94, weight 195 lbs (BMI:28.8), with prominent AV nicking (3:1), and laterally displaced PMI. The patient reports about one pack of cigarette use since age 20 (35 pack/years), poor eating habits and significant familial history of hypertension.